|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$7.01
|
|
|
Service Code
|
NDC 00904713572
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.59 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Aetna American Axle |
$4.56
|
| Rate for Payer: Aetna Commercial |
$5.96
|
| Rate for Payer: Aetna Medicare |
$3.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.56
|
| Rate for Payer: BCBS Complete |
$2.80
|
| Rate for Payer: Cash Price |
$5.61
|
| Rate for Payer: Cofinity Advantage |
$4.91
|
| Rate for Payer: Cofinity Commercial |
$6.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.61
|
| Rate for Payer: Healthscope Commercial |
$6.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.26
|
| Rate for Payer: PHP Commercial |
$5.96
|
| Rate for Payer: Priority Health SBD |
$4.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.56
|
| Rate for Payer: UHC Core |
$3.65
|
| Rate for Payer: UHC Exchange |
$2.75
|
| Rate for Payer: UMR Bronson Commercial |
$2.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.26
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$7.30
|
|
|
Service Code
|
NDC 00904751366
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$6.57 |
| Rate for Payer: Aetna American Axle |
$4.75
|
| Rate for Payer: Aetna Commercial |
$6.21
|
| Rate for Payer: Aetna Medicare |
$3.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.75
|
| Rate for Payer: BCBS Complete |
$2.92
|
| Rate for Payer: Cash Price |
$5.84
|
| Rate for Payer: Cofinity Advantage |
$5.11
|
| Rate for Payer: Cofinity Commercial |
$6.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.84
|
| Rate for Payer: Healthscope Commercial |
$6.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.47
|
| Rate for Payer: PHP Commercial |
$6.21
|
| Rate for Payer: Priority Health SBD |
$4.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.75
|
| Rate for Payer: UHC Core |
$3.80
|
| Rate for Payer: UHC Exchange |
$2.87
|
| Rate for Payer: UMR Bronson Commercial |
$2.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.47
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$7.30
|
|
|
Service Code
|
NDC 00904751372
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$6.57 |
| Rate for Payer: Aetna American Axle |
$4.75
|
| Rate for Payer: Aetna Commercial |
$6.21
|
| Rate for Payer: Aetna Medicare |
$3.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.75
|
| Rate for Payer: BCBS Complete |
$2.92
|
| Rate for Payer: Cash Price |
$5.84
|
| Rate for Payer: Cofinity Advantage |
$5.11
|
| Rate for Payer: Cofinity Commercial |
$6.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.84
|
| Rate for Payer: Healthscope Commercial |
$6.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.47
|
| Rate for Payer: PHP Commercial |
$6.21
|
| Rate for Payer: Priority Health SBD |
$4.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.75
|
| Rate for Payer: UHC Core |
$3.80
|
| Rate for Payer: UHC Exchange |
$2.87
|
| Rate for Payer: UMR Bronson Commercial |
$2.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.47
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$8.40
|
|
|
Service Code
|
NDC 69339015019
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Aetna American Axle |
$5.46
|
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.46
|
| Rate for Payer: Cash Price |
$6.72
|
| Rate for Payer: Cofinity Advantage |
$5.88
|
| Rate for Payer: Cofinity Commercial |
$7.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.72
|
| Rate for Payer: Healthscope Commercial |
$7.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.30
|
| Rate for Payer: PHP Commercial |
$7.14
|
| Rate for Payer: Priority Health SBD |
$5.29
|
| Rate for Payer: UMR Bronson Commercial |
$3.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.30
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$8.40
|
|
|
Service Code
|
NDC 69339015001
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Aetna American Axle |
$5.46
|
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.46
|
| Rate for Payer: Cash Price |
$6.72
|
| Rate for Payer: Cofinity Advantage |
$5.88
|
| Rate for Payer: Cofinity Commercial |
$7.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.72
|
| Rate for Payer: Healthscope Commercial |
$7.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.30
|
| Rate for Payer: PHP Commercial |
$7.14
|
| Rate for Payer: Priority Health SBD |
$5.29
|
| Rate for Payer: UMR Bronson Commercial |
$3.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.30
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$9.32
|
|
|
Service Code
|
NDC 00121127600
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$8.39 |
| Rate for Payer: Aetna American Axle |
$6.06
|
| Rate for Payer: Aetna Commercial |
$7.92
|
| Rate for Payer: Aetna Medicare |
$4.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.06
|
| Rate for Payer: BCBS Complete |
$3.73
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cofinity Advantage |
$6.52
|
| Rate for Payer: Cofinity Commercial |
$8.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.46
|
| Rate for Payer: Healthscope Commercial |
$8.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.99
|
| Rate for Payer: PHP Commercial |
$7.92
|
| Rate for Payer: Priority Health SBD |
$5.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.06
|
| Rate for Payer: UHC Core |
$4.86
|
| Rate for Payer: UHC Exchange |
$3.66
|
| Rate for Payer: UMR Bronson Commercial |
$3.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.99
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$9.32
|
|
|
Service Code
|
NDC 00121127610
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.10 |
| Max. Negotiated Rate |
$8.39 |
| Rate for Payer: Aetna American Axle |
$6.06
|
| Rate for Payer: Aetna Commercial |
$7.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.06
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cofinity Advantage |
$6.52
|
| Rate for Payer: Cofinity Commercial |
$8.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.46
|
| Rate for Payer: Healthscope Commercial |
$8.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.99
|
| Rate for Payer: PHP Commercial |
$7.92
|
| Rate for Payer: Priority Health SBD |
$5.87
|
| Rate for Payer: UMR Bronson Commercial |
$4.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.99
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$7.06
|
|
|
Service Code
|
NDC 63739050610
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna American Axle |
$4.59
|
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna Medicare |
$3.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.59
|
| Rate for Payer: BCBS Complete |
$2.82
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Advantage |
$4.94
|
| Rate for Payer: Cofinity Commercial |
$6.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.65
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.29
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health SBD |
$4.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.59
|
| Rate for Payer: UHC Core |
$3.68
|
| Rate for Payer: UHC Exchange |
$2.77
|
| Rate for Payer: UMR Bronson Commercial |
$2.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.29
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$7.01
|
|
|
Service Code
|
NDC 00904713572
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Aetna American Axle |
$4.56
|
| Rate for Payer: Aetna Commercial |
$5.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.56
|
| Rate for Payer: Cash Price |
$5.61
|
| Rate for Payer: Cofinity Advantage |
$4.91
|
| Rate for Payer: Cofinity Commercial |
$6.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.61
|
| Rate for Payer: Healthscope Commercial |
$6.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.26
|
| Rate for Payer: PHP Commercial |
$5.96
|
| Rate for Payer: Priority Health SBD |
$4.42
|
| Rate for Payer: UMR Bronson Commercial |
$3.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.26
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$7.06
|
|
|
Service Code
|
NDC 63739050601
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna American Axle |
$4.59
|
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna Medicare |
$3.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.59
|
| Rate for Payer: BCBS Complete |
$2.82
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Advantage |
$4.94
|
| Rate for Payer: Cofinity Commercial |
$6.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.65
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.29
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health SBD |
$4.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.59
|
| Rate for Payer: UHC Core |
$3.68
|
| Rate for Payer: UHC Exchange |
$2.77
|
| Rate for Payer: UMR Bronson Commercial |
$2.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.29
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$7.30
|
|
|
Service Code
|
NDC 00904751366
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$6.57 |
| Rate for Payer: Aetna American Axle |
$4.75
|
| Rate for Payer: Aetna Commercial |
$6.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.75
|
| Rate for Payer: Cash Price |
$5.84
|
| Rate for Payer: Cofinity Advantage |
$5.11
|
| Rate for Payer: Cofinity Commercial |
$6.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.84
|
| Rate for Payer: Healthscope Commercial |
$6.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.47
|
| Rate for Payer: PHP Commercial |
$6.21
|
| Rate for Payer: Priority Health SBD |
$4.60
|
| Rate for Payer: UMR Bronson Commercial |
$3.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.47
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$9.32
|
|
|
Service Code
|
NDC 00121127600
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.10 |
| Max. Negotiated Rate |
$8.39 |
| Rate for Payer: Aetna American Axle |
$6.06
|
| Rate for Payer: Aetna Commercial |
$7.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.06
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cofinity Advantage |
$6.52
|
| Rate for Payer: Cofinity Commercial |
$8.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.46
|
| Rate for Payer: Healthscope Commercial |
$8.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.99
|
| Rate for Payer: PHP Commercial |
$7.92
|
| Rate for Payer: Priority Health SBD |
$5.87
|
| Rate for Payer: UMR Bronson Commercial |
$4.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.99
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$8.40
|
|
|
Service Code
|
NDC 69339015001
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Aetna American Axle |
$5.46
|
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Aetna Medicare |
$4.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.46
|
| Rate for Payer: BCBS Complete |
$3.36
|
| Rate for Payer: Cash Price |
$6.72
|
| Rate for Payer: Cofinity Advantage |
$5.88
|
| Rate for Payer: Cofinity Commercial |
$7.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.72
|
| Rate for Payer: Healthscope Commercial |
$7.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.30
|
| Rate for Payer: PHP Commercial |
$7.14
|
| Rate for Payer: Priority Health SBD |
$5.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.46
|
| Rate for Payer: UHC Core |
$4.38
|
| Rate for Payer: UHC Exchange |
$3.30
|
| Rate for Payer: UMR Bronson Commercial |
$3.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.30
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$133.86
|
|
|
Service Code
|
NDC 45802043321
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.90 |
| Max. Negotiated Rate |
$120.47 |
| Rate for Payer: Aetna American Axle |
$87.01
|
| Rate for Payer: Aetna Commercial |
$113.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.01
|
| Rate for Payer: Cash Price |
$107.09
|
| Rate for Payer: Cofinity Advantage |
$93.70
|
| Rate for Payer: Cofinity Commercial |
$115.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.09
|
| Rate for Payer: Healthscope Commercial |
$120.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.39
|
| Rate for Payer: PHP Commercial |
$113.78
|
| Rate for Payer: Priority Health SBD |
$84.33
|
| Rate for Payer: UMR Bronson Commercial |
$58.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.39
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$142.23
|
|
|
Service Code
|
NDC 63824017163
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.58 |
| Max. Negotiated Rate |
$128.01 |
| Rate for Payer: Aetna American Axle |
$92.45
|
| Rate for Payer: Aetna Commercial |
$120.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.45
|
| Rate for Payer: Cash Price |
$113.78
|
| Rate for Payer: Cofinity Advantage |
$99.56
|
| Rate for Payer: Cofinity Commercial |
$122.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.78
|
| Rate for Payer: Healthscope Commercial |
$128.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.67
|
| Rate for Payer: PHP Commercial |
$120.90
|
| Rate for Payer: Priority Health SBD |
$89.60
|
| Rate for Payer: UMR Bronson Commercial |
$62.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.67
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$146.41
|
|
|
Service Code
|
NDC 00904631256
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.42 |
| Max. Negotiated Rate |
$131.77 |
| Rate for Payer: Aetna American Axle |
$95.17
|
| Rate for Payer: Aetna Commercial |
$124.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.17
|
| Rate for Payer: Cash Price |
$117.13
|
| Rate for Payer: Cofinity Advantage |
$102.49
|
| Rate for Payer: Cofinity Commercial |
$125.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.13
|
| Rate for Payer: Healthscope Commercial |
$131.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.81
|
| Rate for Payer: PHP Commercial |
$124.45
|
| Rate for Payer: Priority Health SBD |
$92.24
|
| Rate for Payer: UMR Bronson Commercial |
$64.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.81
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$142.23
|
|
|
Service Code
|
NDC 63824017563
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.58 |
| Max. Negotiated Rate |
$128.01 |
| Rate for Payer: Aetna American Axle |
$92.45
|
| Rate for Payer: Aetna Commercial |
$120.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.45
|
| Rate for Payer: Cash Price |
$113.78
|
| Rate for Payer: Cofinity Advantage |
$99.56
|
| Rate for Payer: Cofinity Commercial |
$122.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.78
|
| Rate for Payer: Healthscope Commercial |
$128.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.67
|
| Rate for Payer: PHP Commercial |
$120.90
|
| Rate for Payer: Priority Health SBD |
$89.60
|
| Rate for Payer: UMR Bronson Commercial |
$62.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.67
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$194.77
|
|
|
Service Code
|
NDC 63824017565
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.70 |
| Max. Negotiated Rate |
$175.29 |
| Rate for Payer: Aetna American Axle |
$126.60
|
| Rate for Payer: Aetna Commercial |
$165.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.60
|
| Rate for Payer: Cash Price |
$155.82
|
| Rate for Payer: Cofinity Advantage |
$136.34
|
| Rate for Payer: Cofinity Commercial |
$167.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.82
|
| Rate for Payer: Healthscope Commercial |
$175.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.08
|
| Rate for Payer: PHP Commercial |
$165.55
|
| Rate for Payer: Priority Health SBD |
$122.71
|
| Rate for Payer: UMR Bronson Commercial |
$85.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.08
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
OP
|
$146.41
|
|
|
Service Code
|
NDC 00904631256
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.17 |
| Max. Negotiated Rate |
$131.77 |
| Rate for Payer: Aetna American Axle |
$95.17
|
| Rate for Payer: Aetna Commercial |
$124.45
|
| Rate for Payer: Aetna Medicare |
$73.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.17
|
| Rate for Payer: BCBS Complete |
$58.56
|
| Rate for Payer: Cash Price |
$117.13
|
| Rate for Payer: Cofinity Advantage |
$102.49
|
| Rate for Payer: Cofinity Commercial |
$125.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.13
|
| Rate for Payer: Healthscope Commercial |
$131.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$117.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.81
|
| Rate for Payer: PHP Commercial |
$124.45
|
| Rate for Payer: Priority Health SBD |
$92.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.17
|
| Rate for Payer: UHC Core |
$76.28
|
| Rate for Payer: UHC Exchange |
$57.54
|
| Rate for Payer: UMR Bronson Commercial |
$54.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.81
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
OP
|
$142.23
|
|
|
Service Code
|
NDC 63824017563
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.63 |
| Max. Negotiated Rate |
$128.01 |
| Rate for Payer: Aetna American Axle |
$92.45
|
| Rate for Payer: Aetna Commercial |
$120.90
|
| Rate for Payer: Aetna Medicare |
$71.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.45
|
| Rate for Payer: BCBS Complete |
$56.89
|
| Rate for Payer: Cash Price |
$113.78
|
| Rate for Payer: Cofinity Advantage |
$99.56
|
| Rate for Payer: Cofinity Commercial |
$122.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.78
|
| Rate for Payer: Healthscope Commercial |
$128.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$113.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.67
|
| Rate for Payer: PHP Commercial |
$120.90
|
| Rate for Payer: Priority Health SBD |
$89.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$92.45
|
| Rate for Payer: UHC Core |
$74.10
|
| Rate for Payer: UHC Exchange |
$55.90
|
| Rate for Payer: UMR Bronson Commercial |
$52.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.67
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
OP
|
$142.23
|
|
|
Service Code
|
NDC 63824017163
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.63 |
| Max. Negotiated Rate |
$128.01 |
| Rate for Payer: Aetna American Axle |
$92.45
|
| Rate for Payer: Aetna Commercial |
$120.90
|
| Rate for Payer: Aetna Medicare |
$71.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.45
|
| Rate for Payer: BCBS Complete |
$56.89
|
| Rate for Payer: Cash Price |
$113.78
|
| Rate for Payer: Cofinity Advantage |
$99.56
|
| Rate for Payer: Cofinity Commercial |
$122.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.78
|
| Rate for Payer: Healthscope Commercial |
$128.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$113.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.67
|
| Rate for Payer: PHP Commercial |
$120.90
|
| Rate for Payer: Priority Health SBD |
$89.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$92.45
|
| Rate for Payer: UHC Core |
$74.10
|
| Rate for Payer: UHC Exchange |
$55.90
|
| Rate for Payer: UMR Bronson Commercial |
$52.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.67
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
OP
|
$194.77
|
|
|
Service Code
|
NDC 63824017565
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.06 |
| Max. Negotiated Rate |
$175.29 |
| Rate for Payer: Aetna American Axle |
$126.60
|
| Rate for Payer: Aetna Commercial |
$165.55
|
| Rate for Payer: Aetna Medicare |
$97.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.60
|
| Rate for Payer: BCBS Complete |
$77.91
|
| Rate for Payer: Cash Price |
$155.82
|
| Rate for Payer: Cofinity Advantage |
$136.34
|
| Rate for Payer: Cofinity Commercial |
$167.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.82
|
| Rate for Payer: Healthscope Commercial |
$175.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$155.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.08
|
| Rate for Payer: PHP Commercial |
$165.55
|
| Rate for Payer: Priority Health SBD |
$122.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.60
|
| Rate for Payer: UHC Core |
$101.48
|
| Rate for Payer: UHC Exchange |
$76.54
|
| Rate for Payer: UMR Bronson Commercial |
$72.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.08
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
OP
|
$133.86
|
|
|
Service Code
|
NDC 45802043321
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.53 |
| Max. Negotiated Rate |
$120.47 |
| Rate for Payer: Aetna American Axle |
$87.01
|
| Rate for Payer: Aetna Commercial |
$113.78
|
| Rate for Payer: Aetna Medicare |
$66.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.01
|
| Rate for Payer: BCBS Complete |
$53.54
|
| Rate for Payer: Cash Price |
$107.09
|
| Rate for Payer: Cofinity Advantage |
$93.70
|
| Rate for Payer: Cofinity Commercial |
$115.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.09
|
| Rate for Payer: Healthscope Commercial |
$120.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$107.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.39
|
| Rate for Payer: PHP Commercial |
$113.78
|
| Rate for Payer: Priority Health SBD |
$84.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.01
|
| Rate for Payer: UHC Core |
$69.74
|
| Rate for Payer: UHC Exchange |
$52.61
|
| Rate for Payer: UMR Bronson Commercial |
$49.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.39
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$61.18
|
|
|
Service Code
|
NDC 00338002302
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.64 |
| Max. Negotiated Rate |
$55.06 |
| Rate for Payer: Aetna American Axle |
$39.77
|
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Aetna Medicare |
$30.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.77
|
| Rate for Payer: BCBS Complete |
$24.47
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Advantage |
$42.83
|
| Rate for Payer: Cofinity Commercial |
$52.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Healthscope Commercial |
$55.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.88
|
| Rate for Payer: PHP Commercial |
$52.00
|
| Rate for Payer: Priority Health SBD |
$38.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.77
|
| Rate for Payer: UHC Core |
$31.87
|
| Rate for Payer: UHC Exchange |
$24.04
|
| Rate for Payer: UMR Bronson Commercial |
$22.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.88
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 00338002304
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Advantage |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.45
|
| Rate for Payer: UHC Core |
$36.43
|
| Rate for Payer: UHC Exchange |
$27.48
|
| Rate for Payer: UMR Bronson Commercial |
$25.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
